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Did You Know?
Coding other physicians' diagnosis(es), including consultant’s documentation that were not included in the discharge summary, is permissible and not considered to be conflicting.
Why It Matters?
Hospitals are missing valuable clinical information that could identify an increased Severity of Illness (SOI), increased Risk of Mortality (ROM) and, possibly an increase in reimbursement, when another physician’s documentation of a diagnosis is not reported. You need to show how sick your patients really are.
What Can I Do?
Review the references below and discuss with management if you are coding only the diagnoses listed on the discharge summary.
- Coding Clinic, 1ST Quarter 2014, page 11
- MMP Article July 1, 2011: MLN Matters – Number SE1121: Recover Audit Program DRG Coding Vulnerabilities for Inpatient Hospitals
- Medlearn Matters SE1121
In the early days of the COVID-19 Public Health Emergency (PHE) guidance and information was coming at us fast and furious by the likes of the CMS, CDC, OIG, and the AMA. Early on, MMP provided weekly COVID-19 updates. We later transitioned to including highlights in our end of the month Medicare updates article.
However, with new codes related to COVID-19 becoming effective April 1, 2022, the recent launch of an OIG telehealth webpage, and CMS announcing the end of specific COVID-19 waivers for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities, and end-stage renal disease facilities, updating our readers couldn’t wait until the end of April.
April 1, 2022: Reminder, New COVID-19 Codes Effective April 1, 2022
As a reminder, effective April 1, 2022, there are new ICD-10-CM diagnosis codes for reporting COVID-19 vaccination status as well as new ICD-10-PCS procedure codes describing the introduction or infusion of therapeutics, including vaccines for COVID-19 treatments.
In a related MLN Matters Article MM12578 (link), “CMS notes that for hospitalized patients, Medicare pays for COVID-19 vaccines and their administration separately from the Diagnosis-Related Group rate. Medicare expects that the appropriate CPT codes will be used when a Medicare patient is administered a vaccine while a hospital inpatient. For details on billing Medicare for the COVID-19 vaccine appropriately, please see this page in our provider toolkit.”
Information about a new Pfizer BioNTech COVDI-19 vaccine code and changes for COVID-19 monoclonal antibody therapy product and administration codes can be found in MLN Matters Article MM12666 (link).
April 4, 2022: New Way for Medicare Beneficiaries to Get Free Over the Counter COVID-19 Tests
In an April 4, 2022, Special Edition of MLN Connects (link), CMS announced that Medicare beneficiaries, including Medicare Advantage enrollees, can now get free COVID-19 tests with a few caveats:
- They must be FDA approved, authorized, or cleared over the counter COVID-19 tests,
- You are limited to up to 8 tests per calendar month from participating pharmacies and health care providers, and
- Free testing is available for the duration of the COVID-19 public health emergency (PHE).
CMS also provided a list of national pharmacy chains participating in this initiative that includes Albertsons Companies, Inc., Costco Pharmacy, CVS, Food Lion, Giant Food, The Giant Company, Hannaford Pharmacies, H-E-B Pharmacy, Hy-Vee Pharmacy, Kroger Family of Pharmacies, Rite Aid Corp., Shop & Stop, Walgreens, and Walmart.
This new option for receiving COVID-19 tests is an addition to the following options outlined in the Special Edition MLN Connects:
- Requesting free over-the-counter tests for home delivery at covidtests.gov. Every home in the U.S. is eligible to order 2 sets of 4 at-home COVID-19 tests.
- Access to no-cost COVID-19 tests through health care providers at over 20,000 testing sites nationwide. A list of community-based testing sites can be found here.
- Access to lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost through Medicare.
- In addition to accessing a COVID-19 laboratory test ordered by a health care professional, people with Medicare can also access one lab-performed test without an order and cost-sharing during the public health emergency.
April 4, 2022: OIG Launches Telehealth Webpage
The OIG announced the launch of a new telehealth webpage (link). In the announcement they note that they are “conducting oversight work assessing telehealth services, including the impact of the public health emergency flexibilities. Once complete, these reviews will provide objective findings and recommendations that can further inform policymakers and other stakeholders considering changes to telehealth policies. This work can help ensure the potential benefits of telehealth are realized for patients, providers, and HHS programs.”
April 6, 2022: CMS to Pay for Second COVID-19 Booster without Cost Sharing
CMS announced (link) that they will pay for a second COVID-19 booster at no cost for people with Medicare or Medicaid coverage. They go on to note that the CDC recently updated their recommendation regarding COVID-19 vaccinations. Specifically, “Certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least 4 months ago are eligible for another booster to increase their protection against severe disease from COVID-19. Additionally, the CDC recommends that adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least 4 months ago can receive a second booster dose of a Pfizer-BioNTech or Moderna COVID-19 vaccine.”
April 7, 2022: CMS Returns to Certain Pre-COVID-19 Policies in Long-term Care and Other Facilities
In a CMS Press Release (link), they note that they have seen steadily increasing vaccination rates for nursing home residents and staff, and improvements in nursing homes’ abilities to respond to COVID-19 outbreaks. This provided the impetus for CMS to announce they will be phasing out certain flexibilities related to the COVID-19 PHE to re-establish certain minimum standards. Some of the same waivers are also being terminated for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), and end-stage renal disease (ESRD) facilities.
Specifically, CMS is ending specific waivers in two groups: one group of waivers will terminate 30 days from the issuance of this new guidance, and the other group will terminate 60 days from issuance. CMS notes in the related memorandum Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers (link), that at this time “applicable waivers will remain in effect for hospitals and critical access hospitals (CAH).”
Note, CMS has updated their COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (link) document to reflect the dates for when the waivers are to terminated.
Did You Know?
The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.
Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.
Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.
In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.
Esophageal Cancer Prevalence in the United States in 2021
- New Cases: 19,260
- Deaths: 15,530
Esophageal Cancer Risk Factors
- Tobacco Use,
- Heavy alcohol use,
- Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus,
- Men are about three times more likely than women to develop esophageal cancer,
- Older age,
- White men develop esophageal cancer at higher rates than Black men in all age groups
Signs and Symptoms of Esophageal Cancer
- Painful or difficult swallowing,
- Weight loss,
- Pain behind the breastbone,
- Hoarseness and cough
- Indigestion and heartburn
- A lump under the skin
Tests Used to Diagnose Esophageal Cancer
- Physical exam and health history,
- Chest x-ray,
Why this Matters?
In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 19.9%.
Patients have a better chance of recovery when esophageal cancer is found early. Only 17.5% of patients are diagnosed with esophageal cancer at the local level. The five-year survival rate for this group of patients is 46.4%.
Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the symptoms, discuss them with your doctor.
- PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 07/15/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389338]
- PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: (link). Accessed 04/04/2022. [PMID: 26389280]
- PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 11/18/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389463]
Medicare Educational Resources
MLN Education Tool: Medicare Payment Systems
CMS alerted readers in the Thursday, March 3, 2022 edition of MLN Connects (link) that the MLN education tool Medicare Payment Systems has been updated to include 2022 regulation changes to payment, quality, and policy across several settings (i.e., acute care hospital, skilled nursing facility, and home health).
MLN Booklet: SBIRT Services Updated
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, early intervention approach for people with non-dependent substance use before they need more extensive or specialized treatment. CMS SBIRT Booklet MLN904084 (link) was recently updated to inform providers that beginning January 1, 2022, CMS covers Naloxone HCPCS Code G1028.
February 28, 2022: CMS COVID-19 FAQs on Medicare Fee-for-Service Billing Documented UpdatedThis CMS document (link) includes FAQs for providers and suppliers that bill Medicare (i.e., labs, hospitals, ambulance services, physician services) and was last updated on February 28, 2022. Specifically, on February 16th, CMS updated the answer to the following question:
- Question: The FDA has expanded the approved indication for the antiviral drug Veklury (remdesivir), and it is now authorized for the treatment of COVID-19 in certain adults and pediatric patients who are not hospitalized in addition to those that are hospitalized. How will CMS pay for remdesivir if it is administered in the outpatient setting?
March 3, 2022: Preliminary Medicare COVID-19 Data Snapshot
Medicare most recently updated their Preliminary Medicare COVID-19 Data Snapshot webpage (link) on March 3rd. The data snapshot reports COVID-19 cases and hospitalization data for Medicare beneficiaries diagnosed with COVID-19. Following are highlights from this data release:
- There have been 1,636,501 total Medicare COVID-19 hospitalizations,
- Of those hospitalized, most beneficiaries (38%) were discharged home. The other top three discharge dispositions include home health (17%), skilled nursing facility (17%), and expired (17%),
- The top five chronic conditions among hospitalized beneficiaries includes hypertension (81%), hyperlipidemia (65%), chronic kidney disease (58%), ischemic heart disease (49%) and diabetes (48%),
- Total Medicare Fee-for-Service payment to date for COVID-19 hospitalizations is $23.4B, and
- The average payment per beneficiary hospitalization with COVID-19 is $24,304.
March 10, 2022: MLN Matters Notice Revised Emergency Use Authorization (EUA) for EVUSHELD
CMS published the following information about a revised EUA for the COVID-19 monoclonal antibody cilgavimab (EVUSHELD) in the March 10, 2022, edition of MLN Matters (link):
“On February 24, the FDA revised the emergency use authorization for tixagevimab co-packaged with cilgavimab (EVUSHELD™) to change the initial dose for the authorized use as pre-exposure prophylaxis of COVID-19 in certain adults and pediatric patients. For more information about dosage and administration, including information about dosing for patients who got the original lower dose, review the fact sheet (ZIP) (link).
- Long Descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg
- Short Descriptor: Tixagev and cilgav, 600mg
Visit the COVID-19 Monoclonal Antibodies webpage for more information (link). Note: you may need to refresh your browser if you recently visited this webpage.”
March 22, 2022: 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)
On March 23rd, CMS updated their COVID-19 Current Emergencies webpage (link) by adding a COVID-19 Medicare Provider Enrollment Relief FAQs document (link). The first question in this document answers the question of how CMS is using its 1135 blanket waiver authority to offer flexibilities with Medicare provider enrollment to support the COVID-19 national emergency.
March 16, 2022: Annual Civil Monetary Penalties Inflation Adjustment PublishedThe Office of the Assistant Secretary for Financial Resources, Department of Health and Human Services (HHS) published the Annual Civil Monetary Penalties Inflation Adjustment Final Rule (link) on March 17, 2022. Examples of actions that can come under a civil monetary penalty includes:
- Penalty for knowing of an overpayment and failing to report and return.
- Penalty for failure to grant timely access to HHS OIG for audits, investigations, evaluations, and other statutory functions of HHS OIG.
- Penalty for a Medicare Advantage organization that substantially fails to provide medically necessary, required items and services.
- Penalty for improper billing by Hospitals, Critical Access Hospitals, or Skilled Nursing Facilities.
Medicare MLN Articles & Transmittals
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year (FY) 2020 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs)
- Article Release Date: February 24, 2022
- What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
- MLN MM12628: (link)
April 2022 Update to the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS)
- Article Release Date: March 7, 2022
- What You Need to Know: This article provides information about coding needs and coding criteria for reprocessing inpatient claims involving Pfizer’s PAXLOVID™ or Merk’s Molnupiravir. Both drugs were granted FDA emergency use authorization in December 2021.
- MLN MM12631: (link)
One-Time Notification: Correction to Processing When Osteoporosis Drugs are Billed for Other Indications
- Transmittal Release Date: March 9, 2022
- What You Need to Know: This Change Request (CR) 12551 permanently removes an edit requiring osteoporosis drugs be billed only by home health agencies.
- Transmittal 11290 (CR 12551): (link)
April Quarterly Update for 2022 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Article Release Date: March 11, 2022
- What You Need to Know: This article provides information about the April 2022 quarterly update for the DMEPOS fee schedule and fee schedule amounts for new and existing codes.
- MLN MM12654: (link)
Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)
- Article Release Date: March 18, 2022
- What You Need to Know: Make sure your billing staff knows about how to code for difelikefalin injection and modifier use for code J0879.
- MLN MM12583: (link)
April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Transmittal 11305/Change Request 12666 Release Date: March 24, 2022
- What You Need to Know: The effective date for the updates is April 1, 2022. Examples of items included in this update are:
- o New COVID-19 CPT vaccines and administration codes,
- o Changes for COVID-19 monoclonal antibody therapy product and administration codes,
- o A new HCPCS code describing the InSpace Subacromial Tissue Spacer System procedure to treat irreparably torn rotator cuff tendons, and
- o New separately payable procedure codes for medical procedures.
- Link to CR 12666: (link)
April 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
- Article Release Date: March 24, 2022
- What You Need to Know: Changes to make your billing staff aware of (updates to payment rates for separately payable procedures, services, drugs, and biologicals and descriptors for newly created CPT and Level II HCPCS codes) are detailed in this MLN article.
- MLN MM12679: (link)
Revised Medicare MLN Articles & Transmittals
Internet-Only Manual Updated for Critical Care Evaluation and Management Services
- Article Release Date: Initial article January 22, 2022 – Revised March 2, 2022
- What You Need to Know: This article was revised to reflect a revised Change Request (CR). All other information is the same. As a reminder, CMS has added language to the definition of a Global Surgical Package to direct you to critical care updates in section 220.127.116.11 of the Medicare Claims Processing Manual, Chapter 12.
- MLN MM12550: (link)
Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache)
- Article Release Date: February 16, 2022
- What You Need to Know: You will learn about revisions to NCD 240.2 and 240.2.2. For example, CMS notes that “Medical documentation requirements aren’t contained within the revised NCDs. The absence of medical documentation in these revised NCDs doesn’t otherwise remove or modify Medicare requirements of the Certificate of Medical Necessity (CMN) Form 484 itself or other medical documentation requirements under other existing authorities.”
- MLN MM12607: (link)
March 1, 2022: CMS Posts New Tracking Sheet for the Cochlear Implantation NCD (50.3)
According to a new Tracking Sheet link), “this NCD analysis will align with the scope of the request and focus on individuals with hearing test scores of > 40% and ≤ 60%, for whom coverage is available only when the provider is participating in, and patients are enrolled in a clinical study.” The initial public comment period is from March 1, 2022, to March 31, 2022.
Did You Know?
It has been over eight years since new discharge status codes (81 through 95) were finalized in the 2014 IPPS Final Rule (link).
The new codes were added to the GROUPER logic for MS-DRGs 280, 281, and 282 to identify those patients diagnosed with an acute myocardial infarction (AMI) who were discharged/transferred to another facility with a planned acute care hospital inpatient readmission alive. Following are pertinent comments from the 2014 final rule regarding these codes:
“The new discharge status codes related to a planned acute care hospital inpatient readmission were developed and approved by the National Uniform Billing Committee (NUBC) in response to a request by the provider community. The purpose of the new codes is to allow providers to track these types of situations when they occur. According to meeting notes from the NUBC, there is not a designated timeframe (or limitation) in reporting these new codes.”
“The planned readmission discharge status codes can also be reported for other MS-DRGs.”
“These new discharge status codes are not related in any way to the Hospital Readmission Reduction Program and will not be taken into account in the readmission measures for that program.”
You will find the discussion about the new codes on pages 50533 and 50534 of the 2014 IPPS Final Rule.
With these codes having been in place since October 1, 2013, I wanted to know if hospitals are using them? To find the answer, I turned to our sister company, RealTime Medicare Data (RTMD). Here is what the data revealed:
- In FY 2021, in the RTMD database, there were 7,898,214 Medicare Fee-for-Service acute inpatient hospital paid claims.
- Of those claims, 12,146 included one of the discharge status codes that includes a planned readmission.
- The top five discharge status codes with a planned readmission by volume were:
- 2,307 claims included discharge status code 81 (Discharged to home or self-care with a planned acute care hospital inpatient readmission),
- 2,185 claims included discharge status code 83 (Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission,
- 1,873 claims included discharge status code 90 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission,
- 1,602 claims included discharge status code 86 (Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission), and
- 1,437 claims included discharge status code 82 (Discharged/transferred to a short-term general hospital with a planned acute care hospital inpatient readmission.
- Top five states using discharge status codes with a planned readmission:
- Florida – 1,281 claims
- Texas – 1,140 claims
- Pennsylvania – 918 claims
- New York - 884 claims
- California – 760 claims
- Bottom five states using discharge status codes with a planned readmission:
- Arkansas – 13 claims
- Ohio – 7 claims
- Vermont – 5 claims
- Hawaii – 3 claims
- Hawaii – 3 claims
Why It Matters?
Assigning the correct discharge status code is important and can be costly if not correct.
The Comprehensive Error Rate Testing (CERT) A/B Medicare Administrative Contractor (MAC) Outreach & Education Task Force has published an education resource titled Patient Discharge Status Codes Matter (link). In this document, the CERT contractor notes they have issued errors related to the incorrect use of Discharge Status Codes that may result in an overpayment or underpayment of Medicare claims.
Incorrect discharge status codes can also cause an admitting facility to not be able to be paid due to the incorrect billing of the acute inpatient hospital.
What Can You Do?
A patient’s discharge disposition can change after the patient has already discharged from your hospital. The CERT contractor encourages hospitals “to follow-up with the patient after discharge and prior to submitting the claim to Medicare to ensure the patient went to the planned facility that was recorded in the medical record. This will prevent incorrect billing of the Discharge Status Code and avoid unnecessary adjustments to claims when the incorrect code is used.”
I encourage you to read the CERT Task Force document as well as the listed resources on this document to help prevent improper payments due to incorrect billing of discharge status codes.
Additional Resource:MLN SE21001 Review of Hospital Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services & Other Information on Patient Discharge Status Codes (link)
Do you know when the COVID-19 Public Health Emergency (PHE) will end?
The COVID-19 PHE declaration was last renewed on January 14, 2022 with an effective date of January 16th (link). When the Secretary of the Department of Health and Human Services (HHS) makes a PHE declaration, it lasts for the duration of the PHE or 90 days but may be extended by the Secretary for as long as the PHE continues to exist. The most recent declaration is set to end April 16, 2022.
Further, in January 2021, acting HHS Secretary Norris Cochran sent a letter to governors across the country to share details about the COVID-19 PHE and indicated in the letter that HHS “has determined that the PHE will likely remain in place for the entirety of 2021, and when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.”
March is National Professional Social Work Month. This year’s the National Association of Social Workers (NASW) is celebrating with the theme “The time is right for social work.” The NASW notes that “The time is always right for social work. However more people are entering the field because the life-affirming services that social workers provide are needed more than ever. This is especially true as our nation continues to grapple with the COVID-19 pandemic, systemic racism, economic inequality, global warming, and other crises.”
A few of the resources available on NASW’s website for your 2022 Social Work Campaign (link) include:
- A Social Work Month 2022 video.
- A quiz to assess how much you know about social work; and
- A document highlighting the theme and rationale for this year’s Social Work Month.
I want to acknowledge and thank all the wonderful social workers that I have worked with or who have been an invaluable resource in my own life when family members have been hospitalized.
The transition of care from a hospital to a post-acute setting can be a very stressful time. As MMP has done in years past, we are providing an updated list of resources to assist with discharge planning.
Resources for You:
- Medicare Costs at Glance for 2022 (link)
- MLN Booklet: Medicare and Medicaid Basics (link)
- MLN Educational Tool: Medicare Payment Systems (link)
- CMS National Training Program Module: 2021/2022 Getting Started with Medicare (link)
Resources for your patients
- Taking Care of Myself: A Guide for When I Leave the Hospital (link)
- Discharge Planning Protects You (link)
- Your Discharge Planning Checklist: For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting (link)
- Your Guide to Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program (link)
- Your Medicare Benefits (link)
- Medicare Hospice Benefits (link)
- Medicare Appeals (link)
From all of us at MMP, Happy Social Work Month!
Collaboration is a process of working together to complete a task or achieve a goal.
For the Clinical Documentation Integrity Specialist, the goal of ensuring a patient’s story can be accurately reflected in codes (ICD-10-CM/PCS, HCPCS, CPT), requires collaborating with a team that can include physicians, nursing, dietitians, physical therapists, case managers, social workers, and coding professionals.
For the Case Manager, to ensure a patient’s story supports medical necessity of the services being provided and the patient has an appropriate discharge plan in place, this process, in addition to the above professions, requires open communication with the patient and his or her “people.”
Physicians must also collaborate with a team. In fact, CMS recently updated their MLN Fact Sheet: Collaborative Patient Care is a Provider Partnership (link). This Fact Sheet opens with the following guidance:
“As a physician, supplier, or other health care provider, you may need to collaborate with other providers when providing care to your Medicare patients. For example, you may:
- Write orders
- Make referrals
- Request health care services or items for your patient
It’s important to understand Medicare coverage criteria and documentation requirements that apply for those services or items. This helps to ensure:
- Quality care for your patient
- Accurate and timely processing and payment of:
- Your claims, and
- The claims of other providers or suppliers who provide services or items for your patient
Note: This fact sheet is limited to information and documentation you need to support medical necessity when you partner with other providers. Other coverage and payment rules may also apply.”
Medicare Coverage Criteria and Documentation Requirements
Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states “No payment may be made under Part A or Part B for expenses incurred for items or services which…are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…”
At the national level, CMS publishes National Coverage Determinations (NCDs) and at the local level, Medicare Administrative Contractors (MACs) publish Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs). Coverage documents provide guidance for when a service is covered or not covered, and include indications for coverage, limitations of coverage, documentation requirements and billing and coding guidance.
It is important to become familiar with where to find these documents (Medicare Coverage Database (link) and identify any NCDs, LCDs, and/or LCAs that apply to services that you provide. For example, at the national level, there is a NCD for Implantable Automatic Defibrillators (20.4) (link). In addition to the NCD, several MACs have published a related Billing and Coding article.
Ensuring the Story is Correct
Understanding Medicare coverage criteria and documentation requirements is important. So much so, CMS utilizes Contractors (i.e., Recovery Auditors, Supplemental Medical Review Contractor, and MACs) to audit claims.
CMS notes in the MLN Fact Sheet, “Medicare audits frequently show that provider-submitted documentation doesn’t provide enough information to establish medical necessity. To ensure proper claims processing and payment, you must follow documentation requirements and meet Medicare coverage criteria.”
They also underscore the importance of documenting everything needed to meet Medicare payment requirements when collaborating with other Providers. For example, let us once again focus on implantable automatic defibrillators and the Shared Decision Making (SDM) encounter requirement. The SDM encounter is:
- A requirement for all patients receiving a defibrillator for primary prevention,
- Must occur between the patient and a Physician or Non-Physician Practitioner (i.e., Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist),
- An Evidenced-Based Decision Tool must be used to ensure topics like patient health goals and preferences are discussed,
- The encounter must occur prior to the initial implantation, and
- The encounter may occur at a separate visit.
Given the timing of when the SDM encounter should occur, it is likely that this would be done in the Physician’s office. Therefore, the physician would need to include in documentation provided to the hospital that an SDM encounter had occurred and what tool had been used.
CMS advises that a providers documentation needs to be thorough and accurate to support the medical necessity of services provided and should:
- Provide a thorough picture of what happened during the patient’s visit, and
- Tell why services or items you ordered or gave are medically necessary.
MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month’s focus is on bariatric surgery.
Did You Know?
There has been a National Coverage Determination (NCD) for bariatric surgery (100.1) since 1979. Originally titled Gastric Bypass Surgery for Obesity, the NCD is now titled Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (link). This name change reflects the fact that treatment for obesity alone remains a non-covered indication for bariatric surgery.
Why Does This Matter?
Bariatric surgery has come under scrutiny by more than one review contractor, for example:
Supplemental Medical Review Contractor (SMRC): Strategic Health Solutions, the first SMRC contractor, completed a review of claims for bariatric service codes for dates of service from January 1, 2014, through December 31, 2014. In their review results, they cited a 35% error rate. The main reason for denials was due to insufficient documentation, for example: documentation did not include information supporting prior unsuccessful medical attempts at weight loss prior to surgical intervention.
Recovery Auditors (RACs): Complex medical reviews of inpatient and outpatient bariatric procedures has been an approved RAC Issue (link) since February 1, 2017.
Office of Inspector General (OIG): More recently, the Office of Inspector General published the report Hospitals Did Now Always Meet Differing Contractor Specifications for Bariatric Surgery (link). The OIG undertook this audit due to findings from a prior review of claims in 2015 and 2016 where they found claims did not fully meet a MAC’s eligibility specifications as well as the variance in eligibility specifications by different MACs. The audit included hospital inpatient claims for bariatric surgery performed from January 2017 through July 2018.
The OIG found thirty-two claims that met the NCD requirements, however the claims did not meet the MACs local specifications in their Local Coverage Determination (LCD) or Local Billing and Coding Article (LCA). Noridian had the most restrictive eligibility specifications in their LCA. The top specification not met was a lack of documentation indicating the beneficiary had participated in a weight management program. Novitas and First Coast had the least restrictive LCDs. The OIG estimated that “Medicare could have saved $47.8 million during our audit period if Medicare contractors had disallowed claims that did not meet Medicare national requirements or Medicare contractor specifications for bariatric surgery.”
OIG Audit Recommendations
Based on the audit findings, the OIG recommended that CMS:
- Determine if any of the MACs eligibility specifications in their LCDs or LCAs should be added to the NCD and if so, take steps to update the NCD,
- Work with the MACs to determine if any of the LCD or LCA eligibility specifications should be requirements rather than guidance, and
- If the NCD is updated, provide education to hospitals on the NCD requirements for bariatric surgery.
CMS did not agree with the OIGs recommendations. Two CMS responses were highlighted in the Report Brief:
- CMS will continue to monitor scientific evidence related to bariatric surgery and evaluate if an update to the NCD is needed, and
- “The Social Security Act does not mandate that LCDs be uniform across all jurisdictions and there are valid reasons that variations at the local Medicare contractor level is appropriate.”
What Can You Do?
If your hospital provides bariatric surgery services, I encourage you to read this OIG Report and perform a record review to ensure documentation supports the NCD requirements and when applicable your MAC LCDs and/or LCAs.
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